Why Not Everyone?

For a while I have considered posting on “the public option” in healthcare that I am most familiar with, the Medicare End-Stage Renal Disease Program. The history of this disease-specific program is fascinating, and I think it provides a good example of what “the public option” could be (and why private insurance companies are scared).

See, you can get public coverage now if:

1. You are employed by the government (like congress)
2. You are or were in the military
3. You are of “retirement age”
4. You are disabled
5. You are poor with dependent children or you are a dependent child
6. You have kidney failure

That’s a whole lot of health care already run by the government. In my experience, it works pretty well with far fewer headaches than many of the private insurers generate.

I was toying with a post about this topic; however, someone has provided a far more compelling story than I could tell as a physician. Jennifer Nix in Salon tells us the history and realities of the Medicare ESRD program through a family saga:

My family's 36-year journey with end-stage renal disease -- the only long-term, chronic disease classification for which the U.S. government provides insurance coverage, regardless of age or income -- offers a telling case study into what once met Congress' standard of an unequivocal, moral imperative to provide public-financed health insurance. My family history mirrors exactly the period from 1973 to 2009, during which this entitlement program has allowed access to life-saving dialysis and kidney transplants, treatments previously denied to all but a very privileged few.

Read the full story: I love my socialist kidney.

We have identified a number of groups for whom we, as a society, feel a moral imperative to provide health coverage. Isn’t it time that a nation with our wealth and spirit extends that opportunity to all of our citizens?

Photo courtesy of PhotoXpress.

Lies, Damn Lies, and NO Statistics

Last week I listened to some of the Sotomayor hearings on CNN. The hearings were about as I expected, but the ads between sessions were frightening. A Canadian woman was on the tube telling me how she would have died of a brain tumor if she hadn’t traveled to the US for treatment.

I have a number of Canadian friends and acquaintances, most of whom are physicians. They LOVE the Canadian system. They know that every patient they see is covered. Layers of administration for preapprovals and claim resubmissions have been peeled away from the process (I have spent 45 minutes on the phone to get non-tablet forms of medications approved for a pediatric patient). And they don’t have to inflate their base charges so that the 80% rate someone negotiated will cover the actual costs incurred. A couple of them have said that Michael Moore got their system right in Sicko. Even those who experience the system as patients like it. Yes, they pay for it with taxes, but they don’t have to worry about losing their coverage with their job.

This ad just didn’t sound right. Elective procedures often involve waits (like they can in the US), but I had never seen a documented life-threatening emergency put off that way. Then I heard this interview  with Maureen Taylor, a health reporter for the Canadian Broadcasting Corporation, on NPR’s On the Media. The full clip is available, and I’ve pasted relevant material from the transcript below, just in case you’re the impatient type:

Shona Holmes is a woman in commercials who says that she would have been dead within a year because doctors in Canada were making her wait six months to have her brain tumor removed. Tumor, in its strictest sense, means a swelling or enlargement. In Shona’s case, it was not cancer:

“What she had was actually a cyst in her pituitary gland, which you can call it a tumor if you want, but it’s not a cancerous tumor. And it was causing her some hormonal problems and pressing on her optic nerve to give her some vision problems.

This is not a life-threatening thing. I don't deny that it would be very disturbing to have vision problems and be told that we're not going to be able to operate on that for six months. So she went to the States and had this done. But nobody at the Mayo Clinic is claiming that they saved her life, yet this is being reported in the American media as a woman with brain cancer who would have been dead had she let the Canadian health care system prevail.

It just makes me angry that the media isn't looking into this a little more. It wasn't hard for me to find out what she actually had and do a little research on it. People, I'm not walking over a lot of dead bodies here on my way into the studio.”

Many of the other commercials feature patients seeking experimental or nonstandard treatments which would generally not be covered under present private insurance in the US.

Healthcare should be a right, not a privilege. Calling what we have in the US a “system” is generally inappropriate, because “system” implies some sort of order or sense. Most healthcare workers will tell you that rhyme and reason are not part of the way we fund medicine in the US.

Forty years ago, we put men on the moon. Today, we still have people who can’t get basic healthcare. Embarrassing, really. Yet we are listening to lies about a real system that works. Even more embarrassing.

Required Reading on Health Care Reform

As a physician, there are many out there who would assume that I want to keep our current US health care "system." They couldn't be more wrong. Daily I experience the waste and inequities of our state of affairs, and I am appalled.

Required reading is this week's cover story from Time Magazine. A health care reporter, Karen Tumulty, describes the hell her brother went through when he was diagnosed with chronic kidney disease, even with an experienced medical reporter in the family to work through the system (or lack thereof). This story is not an isolated incident; this happens to thousand of working Americans every day! It is especially tragic to me when a parent has to change jobs and their children with pre-existing conditions cannot be covered by a new policy.

From my professional perspective, the waste involved with multiple payors is incredible. At our institution we have many people whose job is to figure out what is covered for each patient and to what level. Some patients have multiple sources of coverage. While this sounds like a good thing, what usually happens is that no payor wants to cover anything. When I see the number of people employed just to figure out this transaction, I can't help thinking about how many people could be covered with the funding for these bureaucratic expenses.

Another frustration is the nit-picking that goes on for trivial expenses. One recently discharged patient needed a medication she had previously taken as a pill in patch form. She had been admitted several times because she would vomit the pill and her health issues would decompensate. I had to spend 45 minutes in voice mail hell to get the switch approved. The cost of one admission would cover the difference between pill and patch forms for a long, long time. I can't imaging being a patient, someone not familiar with the system, and trying to jump through these hoops. I'm afraid I would just give up - and many patients do, to the detriment of their health.

The job of the insurance companies is to make money for investors, just like any publicly traded corporation. Spending money on healthcare reduces profits, even if it makes you, the insured person, better. If patients truly had choice, they would pick companies that covered them better over time and others would go out of business. The choice is not in the hands of patients but their employers who are looking at the needs of the group and the business, not the individuals. We need a drastially different approach to healthcare in this country. It's time, America.